J Orthop Sci (2012) 17:551–555
DOI 10.1007/s00776-012-0265-1

ORIGINAL ARTICLE

Responsiveness of the Japanese version of the patient-rated wrist
evaluation (PRWE-J) and physical impairment measurementsin evaluating recovery after treatment of ulnocarpal abutment
syndrome
Shohei Omokawa • Toshihiko Imaeda • Takuya Sawaizumi •Toshimitsu Momose • Hiroyuki Gotani • Yukio Abe •Hisao Moritomo • Fuminori Kanaya
Received: 13 February 2012 / Accepted: 11 June 2012 / Published online: 19 July 2012Ó The Japanese Orthopaedic Association 2012

Abstract
Background We evaluated the responsiveness of patientderived questionnaires and physical findings in evaluating
recovery after treatment of ulnocarpal abutment syndrome.
Methods Patients were assessed at their initial visit to ourclinic and again 3 months after the treatment. At each
visit, patients completed a Short Form-36, the JapaneseSociety for Surgery of the Hand version of Disability of
the Arm, Shoulder, and Hand questionnaire (DASHJSSH), and the Japanese version of patient-rated wrist
evaluation (PRWE-J). Grip strength, range of motion, andvisual analogue scale for wrist pain were also examined ateach visit. Satisfaction with treatment was questioned
after 3 months using a Likert scale. Standardized responsemeans (SRM) and effect sizes were calculated to evaluate
the responsiveness.

The Clinical Outcomes Committee of the Japanese Orthopaedic
Association and the Impairment Evaluation Committee of theJapanese Society for Surgery of the Hand.
S. Omokawa (&)
Department of Orthopaedic Surgery, Nara Medical University,
840 Shijo-cho, Kashihara 634-8522, Japane-mail: omokawa@gaia.eonet.ne.jp
T. Imaeda
Department of Food and Nutritional Environment,College of Human Life and Environment,
Kinjo Gakuin University, Nagoya, Japan
T. Sawaizumi
Department of Orthopaedic Surgery,
Nippon Medical School, Tokyo, Japan

Results The PRWE-J (SRM, 1.35) was the most responsive questionnaire, followed by the DASH-JSSH (SRM,0.81) and the Short Form-36 (SRM, -0.38 to -1.19). Of
the physical tests, grip strength (SRM, 0.81) was more
responsive than range of motion (SRM, 0.01 to -0.29).
The visual analogue pain scale (SRM, 1.56) was highly
responsive. Changes in the PRWE score were correlatedwith the satisfaction rating for the treatment.
Conclusions Responsive patient-derived scales can assist
in the outcome evaluation of patients with ulnocarpal
abutment syndrome.

Introduction
After treatment of musculoskeletal disorders, the outcome
has conventionally been measured by the range of motion,muscle strength, radiographic appearance, and the subjective judgment of the examiner. These conventional
outcome measurements are not clearly correlated with how
H. Gotani
Seikeikai Osaka Trauma and Microsurgery Center, Osaka, Japan
Y. AbeDepartment of Orthopaedic Surgery, Saiseikai Shimonoseki
General Hospital, Shimonoseki, Japan
H. Moritomo
Department of Physical Therapy,
Osaka Yukioka College of Health Science, Osaka, Japan
F. Kanaya
Orthopedic Surgery, Department of Clinical Neuroscience,
Faculty of Medicine, University of the Ryukyus, Okinawa, Japan

T. Momose
Department of Orthopaedics, Suwa Red Cross Hospital,
Suwa, Japan

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the patient assesses the clinical result. Over recent decades,
patient-based instruments have been introduced to evaluate
function and disability after disorders of different parts ofthe musculoskeletal system [1]. Some of these are generic
instruments, such as the Short Form (SF)-36 [2] and sickness impact profile [3]. These generic measures assess theimpact of musculoskeletal problems on the overall healthand well-being of patients, and they were designed forbroad use with a variety of disorders. In the field of upperlimb injuries and diseases, the Disabilities of the Arm,
Shoulder, and Hand (DASH) questionnaire has evolved as
an important self-reported instrument [4–7].
The patient-rated wrist evaluation (PRWE) was specifically designed to reflect the function of the wrist, while theDASH takes the whole upper extremity into account. Previous studies have found the PRWE to be a valid andresponsive questionnaire with regard to wrist function [8,9]. Imaeda et al. [10] investigated the reliability, validity,
and responsiveness of the Japanese version of the PRWE
(PRWE-J) and concluded that the evaluation capacity of
the PRWE-J was equivalent to that of the original PRWE.
In the present study, we aimed to investigate theresponsiveness of the PRWE-J questionnaire and physicaltesting in evaluating recovery after treatment of ulnocarpal
abutment syndrome.

Materials and methods
Thirty-two patients agreed to be included in the study. All
patients were asked to complete the PRWE-J, the JapaneseSociety for Surgery of the Hand version of the DASH(DASH-JSSH), and SF-36 questionnaires, and the visual
analogue scale (VAS) for wrist pain was evaluated at theinitial visit and 3 months after treatment of ulnocarpal
abutment syndrome (UAS). SF-36 Japanese version 2.0
was used, and norm-based scoring was adopted for the
analysis. The mean age of the patients was 56 years, with arange of 21–89 years. There were 14 males and 18 females,
and the dominant wrists were affected in 20 patients. The
duration of symptoms prior to the initial visit averaged
17 months (range, 3–82 months). Diagnosis of the disease
was determined by physical examination and standard X-ray
findings; it was confirmed by MRI or arthroscopic findings.
Treatment consisted of conservative treatment, such as braceand/or medication, in six patients and surgical treatment ofulnar shortening osteotomy in 26 patients.
Grip strength was measured using a Jamar dynamometer(Sammons Preston Rolyan, IL, USA), and the percentage
of grip strength (%GS) was determined as the relative grip
strength of the affected wrist compared with the contralateral side. The range of the wrist and forearm motions
was measured using a standard goniometer. The angles

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tested were those of radial and ulnar deviation, flexion andextension, and pronation and supination. A standard dorsal
technique was used for the wrist flexion and extension [11].
A standard dorsal alignment along the third metacarpal andforearm, with the wrist as fulcrum, was used for the wrist
deviations [12]. Forearm rotation was measured using aperpendicular axis, and either the proximal wrist crease orjust proximal to the ulnar head were the landmarks for
placing the moving arm of the goniometer [13]. The rangeof motion of the affected wrist was evaluated as a proportion of the active range of forearm and wrist movement(%ROM) compared with the contralateral side. The percentage of flexion–extension movement (%FEM) was
defined as the proportion of the range of active flexion–
extension motion of the wrist joint compared with thecontralateral hand. The percentage of radial and ulnar
deviation movement (%RUM) was determined as that ofactive radial and ulnar deviation motion; the percentage ofsupination and pronation movement (%SPM) was similarly
derived from supination and pronation motion. Threemonths after treatment, patient satisfaction with the treatment was assessed using a four-point Likert scale (verysatisfied, satisfied, neutral, dissatisfied).
The responsiveness of all the instruments was examinedby calculating the standardized response mean (SRM;
mean change/SD) and effect size (ES; mean change/SD of
the baseline value). An SRM [0.8 indicated a largechange; 0.5–0.8 indicated moderate change; and \0.5
indicated a small change [14].
As an additional indicator of responsiveness, the correlation between patient satisfaction with the results oftreatment and the improvement in each score was calculated. Good correlation suggested that the score was sensitive to changes in the clinical picture in the patients with
UAS. The study design was approved by the institutional
review board of the hospital. All subjects were informedthat the data from their cases would be submitted for
publication, and they gave their written consent to participate in the study.

Statistical analysis
A comparison was made between the first and second
measurements to assess the clinical change in each patientrated questionnaire and objective findings. A paired t test
and Wilcoxon signed-rank test were used for comparative
analysis. The correlations were calculated between changes
in each score of the PRWE-J, DASH-JSSH, and SF-36, andchanges in objective findings, such as %GS and %ROM,
were assessed by means of Spearman’s correlation coefficient. The correlations of changes in each subscale of the
PRWE-J with changes in %GS and %ROM were analyzed

Responsiveness of patient-rated wrist evaluation

553(-1.19/-1.83) and the PRWE-J function subscale (1.10/
0.98). The SRMs of objective findings and visual analogue
pain score were 1.56 in VAS, –0.36 in %GS, and 0.01 to-0.29 in %ROM (Table 2).
The change in the PRWE-J usual function subscalescore had a significant correlation with changes in %SPM
(r = 0.43, p \ 0.05). The change in the PRWE-J score hada significant correlation with patient satisfaction (r = 0.44,
p \ 0.05) (Table 3). Changes in the DASH–JSSH, bodily
pain, physical function, role-physical scale, mental health,and general health as assessed with the SF-36 had a significant correlation with patient satisfaction.

using Spearman’s coefficient. Correlations between changes in the PRWE-J, DASH-JSSH, SF-36, and patients’satisfaction were calculated using Spearman’s coefficient.
A p value of less than 0.05 was considered significant. We
used the Statistical Package for Social Science (SPSS)
version 16.0 J software for Windows for the statisticalanalysis (SPSS Inc., Chicago, IL, USA).

Results
A significant clinical change between the first and thesecond measurement was observed in the PRWE-J, DASHJSSH, and VAS as well as several subscales of SF-36 and%FEM (p \ 0.01). The mean scores improved from 55
points at baseline to 25 points at the time of follow-up for
the PRWE-J, from 42 to 23 points for the DASH-JSSH
score, and from 60 to 22 points for the VAS. Responsiveness was calculated for the total score of the PRWE-J
as well as for the separate subscales and other measurement
scales (Table 1). The standardized response means were1.35 for the PRWE-J, 0.81 for the DASH-JSSH score, and-0.38 to -1.19 for the SF-36. The largest responsivenessof subscales was observed in the PRWE-J pain subscale(SRM/ES, 1.33/1.76), followed by the SF-36 bodily pain

Discussion
The current results demonstrate that the PRWE-J, which isa specific questionnaire relating to the wrist, is highly
responsive in detecting clinical changes in UAS. The
PRWE-J had a greater SRM than the DASH-JSSH and the
SF-36, and it was demonstrated to be the most responsive
instrument in the current study. The pain and function
subscale of the PRWE-J attained a high responsiveness(SRM, 0.89–1.76), whereas the SF-36 general health(SRM, –0.68), vitality (SRM, 0.54), social function

Table 1 Responsiveness of patient-derived outcome measures in ulnocarpal abutment patients
NumberPreoperative

Postoperative

Preoperative–postoperative

Mean

Mean

Mean

SD

SD

MedianResponsiveness
SD

SRM

ES

PRWE-P***

32

31.38

9.43

14.75

11.36

16.63

17.50

12.53

1.33

1.76

PRWE-SF***

31

31.44

19.53

13.55

14.30

17.32

17.00

18.52

0.94

0.89

PRWE-UF***

26

18.67

11.88

8.64

7.28

11.38

11.00

11.25

1.01

0.96

PRWE-F***

26

24.52

15.35

11.11

10.28

15.12

10.75

13.70

1.10

0.98

PRWE***

26

55.45

23.42

25.32

20.44

33.38

27.75

24.81

1.35

1.43

DASH***

30

41.69

22.18

22.98

18.43

19.24

13.09

23.64

0.81

0.87

SF-36-PF***

31

39.05

12.08

46.39

10.83

-10.15

-7.04

15.59

-0.65

-0.84

SF-36-RP**

31

28.36

17.76

39.96

13.35

-14.12-10.23

17.52

-0.81

-0.79

***

SF-36-BP

31

31.52

8.26

44.32

9.26

-15.11-13.72

12.72

-1.19

-1.83

SF-36-GH*

31

43.68

10.47

48.16

9.10

-7.08

-3.78

14.62

-0.48

-0.68

SF-36-VT

31

43.34

11.74

47.07

7.96

-6.35

-3.08

15.41

-0.41

-0.54

SF-36-SF

31

43.07

15.52

47.13

12.81

-7.08

0.00

18.66

-0.38

-0.46

SF-36-RE***

31

34.32

17.03

42.85

13.43

-11.33

-8.50

13.70

-0.83

-0.67

SF-36-MH*

31

40.34

14.51

45.60

10.14

-7.80

-2.66

16.09

-0.48

-0.54

SRM standardized response mean, ES effect size, PRWE-P pain subscale of the patient-rated wrist evaluation Japanese version, PRWE-SF
specific function subscale of the patient-rated wrist evaluation Japanese version, PRWE-UF usual function subscale of the patient-rated wrist
evaluation Japanese version, PRWE-F function subscale of the patient-rated wrist evaluation Japanese version, DASH disability/symptom scaleof the Japanese version of DASH, SF-36-PF physical functioning subscale of the 36-item short-form health survey (SF-36), SF-36-RP rolephysical subscale of SF-36, SF-36-BP bodily pain subscale of SF-36, SF-36-GH general health subscale of SF-36, SF-36-VT vitality subscale ofSF-36, SF-36-SF social functioning subscale of SF-36, SF-36-RE role-emotional subscale of SF-36-MH, mental health subscale of SF-36* Significant difference between preoperative and postoperative median value (P \ 0.05)** Significant difference between preoperative and postoperative median value (P \ 0.01)*** Significant difference between preoperative and postoperative median value (P \ 0.001)

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S. Omokawa et al.

Table 2 Responsiveness of physical findings and VAS for wrist pain in ulnocarpal abutment patients
NumberPreoperative

Postoperative

Preoperative–Postoperative

Mean

SD

Mean

SD

Mean

ResponsivenessMedian

SD

SRM

ES

VAS pain***

32

60.31

19.12

21.88

18.57

38.44

37.00

24.62

1.56

2.01

% GS

30

71.06

32.33

78.44

24.27

-9.44

-6.70

26.12

-0.36

-0.29

% FEM*

23

84.67

22.98

92.76

12.61

-6.12

-5.72

21.29

-0.29

-0.27

% SPM

23

97.48

30.52

101.96

34.49

-1.61

0.00

22.93

-0.07

-0.05

% RUM

20

85.03

39.86

87.44

22.34

0.25

-9.81

33.39

0.01

0.01

SRM standardized response mean, ES effect size, VAS pain visual analogue scale for wrist pain, % GS a proportional grip strength of the affectedwrist compared to the contralateral side, % FEM a proportion of range of active flexion–extension movement of the affected wrist compared withthe contralateral hand, % RUM a proportional active radial and ulnar deviation motion of the affected wrist compared to the contralateral side, %SPM a proportional active supination and pronation motion of the affected extremity compared to the contralateral side
* Significant difference between preoperative and postoperative median value (P \ 0.05)*** Significant difference between preoperative and postoperative median value (P \ 0.001)

Table 3 Correlation between change scores of each questionnaire
and physical finding, satisfaction
Instrument

Correlation with
% GS

% FEM

% RUM

% SPM

Satisfaction

PRWE-P-0.047-0.030-0.269-0.104-0.435*

PRWE-SF-0.224-0.045-0.406-0.133-0.294*

PRWE-UF
PRWE-F-0.208-0.256-0.268-0.222-0.347-0.381-0.433-0.325-0.425*-0.663*PRWE-0.230-0.164-0.310-0.327-0.447*DASH-0.356-0.159-0.290-0.214-0.576**SF-36-PF-0.027-0.073-0.150-0.100-0.463*SF-36-RP-0.274-0.104-0.100-0.099-0.496**SF-36-BP-0.181-0.128-0.187-0.040-0.672**SF-36-GH-0.104-0.199-0.224-0.024-0.587**

SF-36-VT-0.275-0.075-0.187-0.139-0.189SF-36-SF-0.180-0.384-0.271-0.054-0.383SF-36-RE-0.258-0.132-0.000-0.139-0.197

SF-36-MH*-0.222-0.008-0.059-0.423*-0.379PRWE-P pain subscale of the patient-rated wrist evaluation Japaneseversion, PRWE-SF specific function subscale of the patient-rated
wrist evaluation Japanese version, PRWE-UF usual function subscaleof the patient-rated wrist evaluation Japanese version, PRWE-F
function subscale of the patient-rated wrist evaluation Japanese version, DASH disability/symptom scale of the Japanese version of
DASH, SF-36-PF physical functioning subscale of the 36-item shortform health survey (SF-36), SF-36-RP role-physical subscale of SF36, SF-36-BP bodily pain subscale of SF-36, SF-36-GH general
health subscale of SF-36, SF-36-VT vitality subscale of SF-36, SF-36SF social functioning subscale of SF-36, SF-36-RE role-emotional
subscale of SF-36-MH, mental health subscale of SF-36* P \ 0.05, ** P \ 0.01; Spearman’s correlations (rs) boldface
results indicate a significant correlation, when P \ 0.05 and |rs| [ 0.4(SRM, –0.46), role-emotional scale (SRM, –0.67), andmental health (SRM, –0.54) resulted in a statistically lower
responsiveness. The responsiveness of the PRWE-J was
greater than that with measurement scales of physical123

impairment, such as range of wrist motion and grip
strength. Relatively short-term follow-up after the current
treatment may have contributed to the lower responsiveness of psychosocial subscales of the SF-36 and objective
measurement scales. MacDermid et al. [8] compared the
responsiveness of the DASH, PRWE, and SF-36 scores in
evaluating recovery after distal radius fractures. The
PRWE score was the most responsive of the three in thatgroup of patients (SRM, 2.27), followed by the DASH
(SRM, 2.01) and the SF-36 (SRM, 0.92). This indicatesthat the PRWE score is a reasonably sensitive tool forassessing the outcome in patients with distal radius fractures. The current results are comparable with those of
MacDermid et al., and the PRWE-J was found to be asensitive measurement scale for patients with chronic ulnar
wrist pain. Because of the high responsiveness, using the
PRWE-J would minimize sample-size requirements forevaluating clinical trials for various wrist problems.
The result of a significant correlation between improvement in the PRWE-J and patient satisfaction indicated anotheraspect of the responsiveness with the PRWE-J. Althoughpatient satisfaction generally focuses on clinical interaction
with respect to a specific health-care service, achieving apainless wrist with greater functionality yielded higher satisfaction among the patients in the present study.
Improvement of normal wrist function with the PRWE-J
was significantly correlated with changes in forearm supination and pronation after treatment of UAS, whereas
almost no correlation was found between the function
subscale of the PRWE-J and change in grip strength or
flexion–extension motion. This result indicates that functioning of forearm rotation may be more important fordaily living activities than wrist flexion–extension motion
with powerful grip strength.
The limitation of the present study was the small number of patients with a short-term follow-up. A larger cohort

Responsiveness of patient-rated wrist evaluation

with long-term observation will elucidate the differences in
responsiveness with various treatment modalities. Nevertheless, the responsiveness of the PRWE-J in evaluating
patients with UAS was clearly demonstrated with thepresent series, probably as a result of the homogeneous
population with relatively strict diagnostic criteria.
Conflict of interest None of the authors received any benefits orfunds from any commercial party or company directly or indirectly
related to the subjects of this article.

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